Dercum's disease (Adiposis Dolorosa) questionnaire

Dercum's disease (Adiposis Dolorosa) Questionnaire

Please fill out this questionnaire if you are so inclined. I am doing my own research as I do not see any doctors doing it. Thanks. NOTE: Make sure that the URL for this page DOES NOT have a squiggle in it, (i.e., it does not look like: /~Dercums_Data). If it does, go to this page (same questionnaire) before you start filling in the blanks. Thanks!

NOTE TO TRAVEL SPAMMER -- Please stop. You fill up the buffer space and no one can fill out the questionnaire. And NO ONE sees the URLs. Thanks.

One recent oddity has been seen -- if, after filling out and submitting the questionnaire, you get an error that says:

FrontPage Error.

User: please report details to this site's webmaster.

Webmaster: please see the server's system log for more details.

Don't get upset.

Your answers did get registered, and I can get access the answers. If you want confirmation, send me an e-mail. If it does something else, tell me what it did ;-) I'm sorry for all this hassle, but the problem seems to be that I have an old copy of Microsoft FrontPage (web publisher).

First Name: Last Name:

e-mail address: (don't forget the "@")

Address:

City: State:

Country: Postal code:

Telephone:

Sex: Female Male Age:

-----Start of the questions-------

Yes No Do you have arthritis or arthritis type disease or symptoms.

Describe:

Yes No Chemical sensitivities

Describe:

Yes No Sugar metabolism problems

Describe:

Yes No Hormonal difficulties - menstrual history, pregnancies, etc.

Describe:

Yes No Other hormonal difficulties

Describe:

Yes No Food allergies or sensitivities

Describe:

Yes No Any family members with same or similar symptoms

Describe:

Yes No Circulatory problems

Describe:

Yes No Anemias

Describe:

Yes No Sweating

Describe:

Yes No Dehydration

Describe:

Yes No Itchiness

Describe:

Yes No Swelling in joints

Describe:

Yes No Weakness

Describe:

Yes No Loss of memory

Describe:

Yes No Body temperature abnormalities - too hot or too cold

Describe:

Yes No Digestive disturbances

Describe:

Yes No Stabbing pains

Describe: Where?

Yes No Dental problems (sensitivity to the filling material?, other)

Describe:

Yes No Do you have tumors?

When did tumors begin?

Where are they located?

DESCRIBE:

If they are sensitive to: Touch, Pressure, Sound, Light, Other:

Sensitivities:

If they are better or worse with periods (women only), or if there a
cyclical quality to the tumors erupting, getting bigger, smaller, itching, etc.

Describe Variability:

Are the Tumors diffuse or encapsulated or both (different in various regions?)

What type in which region?

Yes No Drug Allergies?

Describe:

Yes No Steroid use?

Yes No DHEA ingestion?

Yes No Do you suffer from yeast infections?

Yes No Have you ever had shingles?

Other comments:

Version 1.02

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Last updated 15 June 2007

Comments about the web page format
should be sent to the Don

The information submitted on this form will remain confidential. It will be used to develop anonymous trend data concerning this disease which can be passed on to interested doctors. If more personal data is needed, you will be asked if you are willing share your identity . Furthermore, please don't forget that the information provided on this site is designed to support, not replace, the relationship that exists between a patient and her or his physician.